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Readers Write 2/17/09

February 16, 2009 Readers Write 3 Comments

Response to EHR Outcomes Studies Cited by Reader "Pragma"
By Frank Fontana

The author (Pragma) commenting on MD Leader 1/27/09 needs to come clean on their own studies cited before criticizing someone else in such a sarcastic manner.

I followed the links to the "studies" cited. All but one either (a) have nothing to do with studying whether EHRs improve quality or not, or (b) were authored by those in the business of promoting EHRs. The one that does make an attempt to measure quality improvements acknowledges that their work may be skewed towards positive results because of the self-selecting clinics that participated.

I imagine the commenter could also readily cite studies showing that cigarettes weren’t damaging to one’s health, conveniently not mentioning the fact they were funded by tobacco companies.

http://www.bmj.com/cgi/content/full/bmj%3b330/7491/581
This was authored by IT clinical consultants.

http://www.itif.org/files/HealthIT.pdf
This is not a study. The author is an analyst at the Information Technology and Innovation Foundation, which is committed to articulating and advancing a pro-technology public policy agenda.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2253693
This is not an EMR study. It is a study of an electronic prescribing application, funded by the very same vendor.

http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=685103 
The report “examines the experiences of five provider organizations in developing, testing, and implementing quality-of-care indicators, based on data collected from their electronic health record (EHR) systems." It is not a study of whether EHRs improve quality or not.

http://www.cchit.org/about/casestudies/index.asp
This was a study by the Certification Commission for Healthcare Information Technology, which notes that “Case studies bring CCHIT’s work alive.”

http://www.fhin.net/eprescribe/Benefits/AdvantagesToProviders.shtml
Not an EHR study. Another electronic prescribing study, again funded by a provider of electronic prescribing applications.

http://www.fiercehealthit.com/story/ehrs-boost-quality-raise-costs-at-community-clinics/2007-01-22
Link is to a “leading source of Healthcare IT news with a special focus on … EMR adoption…” The study itself notes that five of the six clinics lost money on their EHRs, though quality improved. Regarding the improvement of quality, the study also notes “this retrospective, qualitative study obtained data from a small, purposeful sample of six CHCs, with additional information from two network ASPs. Study CHC cases likely were more successful than cases that declined to participate.” One of the two authors is a graduate student in Biological and Medical Informatics.

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1479999
Not an EHR study. Not a study at all. Rather its a report by a large group practice of its experience integrating an online communication channel with its already existing EMR.

Point of Diagnostic Service (PODS) – Enterprise Diagnosis Oriented Architecture
By The Alchemist

Parallel processes of manufacturing companies operating disparate systems for producing goods sold in the marketplace correlates to analytic processes driving the medical community exotic and disparate diagnostic testing on human subject typically referred as “patient.”  The extent of the diagnostic testing or physiologic surveillance depends on the complexity of the test entity, POS environment, and the instrumentation employed to product the sub-clinical finding commonly called “tests results” or real-time somatic analytics.

Often more times than necessary, these clinical tests or surveillance systems are performed while the patient takes up temporary residence in a full-service acute care health center with state-of-the-art equipment employing all the modern instrumentation afforded to the hospital in the medical service area. These tests can be diverse as Magnetic Resonance Imaging (MRI) to the simple blood test for Magnesium (Mg) or measurement of body temperature. 

If one were to count up the total testing menu provided by a typical urban hospital charge master, the resulting number of frequently reimbursed test procedures would be over two thousand, continually increasing as technology proliferates in the diagnostic in vivo market. If each and every testing procedure performed by a healthcare entity were available online and accessible to everyone involved in the medical process, then this paper would not be necessary and no new information would be reported.  This sadly, is not the case.

The purpose of this paper to examine the multitude of diagnostic testing being performed by accredited hospitals on their patients to consider an interoperability gateway called Point of Diagnostic Service (PODS). Simply stated, Diagnosis Oriented Architecture (DOA) is the underlying structure, or more appropriately surrogate architecture, to service oriented architecture (SOA) supporting communications between clinical service diagnostics. In this context, a diagnostic is defined as a unit of work to be performed on behalf of some computing entity, such as clinical diagnostic instrumentation or medical devices.

DOA defines how two computing entities, such as programs, interact in such a way as to enable one entity to perform a unit of work on behalf of another entity. Diagnostic interactions are defined using a description language equivalent to service oriented architecture.  Each diagnostic interaction is self-contained and loosely coupled, so that each interaction is independent of any other interaction. If one diagnostic entity is non-functional, the service structure will maintain functionality*.

Enterprise diagnostic process, usually initiated by Computerized Provider Order Entry (CPOE) protocols, can be orchestrated by communications between the Web services and gateway diagnostics talking to other gateway diagnostics executed by the underlying framework that DOA provides as a surrogate function to the Enterprise Service Bus. The patient in this case study is the central focus of all medical activity emanating pathophysiologic signaling functioning as medical broadband for investigation to determine cause and effect of presentational or prodromal symptomatology.

NOTE: The foundation for the “Interoperable Patient” is Point of Diagnostic Service (PODS) unified platform, the first critical inch of HIT considered the ecatheter for diagnosis extraction, transformation, and loading of clinical data into the longitudinal enterprise diagnostic repository or colloquial “The Patient Cloud.”

*Advancing the Adoption of Medical Device “Plug & Play” Interoperability to Improve Patient Safety and Healthcare Efficiency.” Center for Integration of Medicine & Innovative Technology. 2008.  http://mdpnp.org/uploads/MD_PnP_White_Paper_April_2008.pdf

HITECH Problem
By Palo Alto Consumer Advocate

The bulk of the HIT language in the bill is pulled directly out of the HR 6357, which Dingle introduced last summer. I don’t see how  NeHC is going to serve as the Policy Advisory committee since the language requires the Policy Committee to have a dramatically different makeup that will mostly be political appointments. For anyone who has ever run a complex project, there is a huge difference between staying close to your stakeholders and asking them to serve on your board of directors. The NEHC board was the result of a six-month open process and the governance model and board composition was designed to include people with multiple areas of expertise. This bill just destroyed that process.

Membership and Operations

(1) IN GENERAL- The National Coordinator shall provide leadership in the establishment and operations of the HIT Policy Committee.
(2) MEMBERSHIP- The HIT Policy Committee shall be composed of members to be appointed as follows:

(A) One member shall be appointed by the Secretary.
(B) One member shall be appointed by the Secretary of Veterans Affairs who shall represent the Department of Veterans Affairs.
(C) One member shall be appointed by the Secretary of Defense who shall represent the Department of Defense.
(D) One member shall be appointed by the Majority Leader of the Senate.
(E) One member shall be appointed by the Minority Leader of the Senate.
(F) One member shall be appointed by the Speaker of the House of Representatives.
(G) One member shall be appointed by the Minority Leader of the House of Representatives.
(H) Eleven members shall be appointed by the Comptroller General of the United States, of whom–

(i) three members shall represent patients or consumers;
(ii) one member shall represent health care providers;
(iii) one member shall be from a labor organization representing health care workers;
(iv) one member shall have expertise in privacy and security;
(v) one member shall have expertise in improving the health of vulnerable populations;
(vi) one member shall represent health plans or other third party payers;
(vii) one member shall represent information technology vendors;
(viii) one member shall represent purchasers or employers; and
(ix) one member shall have expertise in health care quality measurement and reporting.


Knowing Your Clinical Client
By HIT Project Manager

This is not a direct response to any article or comment made, but just a moment of serendipity this morning as I conducted a walk-through of one of our endoscopy units.

IT work is crucial to the performance of the unit. They are increasingly going digital with their process as endoscopic imaging merges with the rest of the electronic medical record.

Some observations as I walked around:

Doubling unit volume shows up in the “seams”
Each room in the unit has had to deal with added technology requirement as an afterthought. Its like how our homes look after choosing a builder’s model where one of the four bedrooms can be made a home office since you’re only having two kids. Once you’ve had four children instead, the home office is now a storage room, the wiring is outdated, and you will need to switch out the old DSL modem for broadband wireless solution if you ever get a chance to use the room for an office. Meanwhile, your PC sits on a cardboard box because the IKEA desk is in offsite storage to make more room.

Clinicians do not have time to learn technology 
Clinicians truly appreciate when we don’t insult their intelligence and years of clinical training by talking down to them and instead speak to one another as colleagues/peers. I love working with and for clinicians for this reason. They are some of the most gracious people you meet when you give them the same respect and care they give, like the RN supervisor on this unit. It is a true joy to work with her and serve her technology needs.

Technologists cannot afford to be oblivious to clinical workflow
In contrast to my last thought, I don’t think technologists (at least those like me in a project management/clinical analyst role) can afford not to get into the weeds of how and where clinicians work. If you do not spend enough time in the unit you provide technology support for, you will inevitably be the “home builder” that sells the client on a “home office” when you should have more appropriately advised a wireless solution. Only a visit to the clinical unit will permit you to forecast the growth that the clinician tries to communicate in the 10 minutes they have between cases.

The devil is in the details, they say.  Being an eternal optimist with a healthy dose of reality, I see that the optimal technology solution is the one that is completely transparent to its end users. Such a solution should work effortlessly and invisibly since, in the end, it’s the clinician-patient relationship that really matters. We technologists remove the distractions to help foster that relationship. 

The article in the Sacramento newsletter commenting on Kaiser-based clinicians’ struggle between time with technology vs. time with patient is a bit overstated, in my assessment. I can’t think of any physician or nurse I met that I who would say they are less effective because of the technology improvements that have been implemented. At worst, they consider them neutral to their work, and they have come up with creative workarounds where they are not. At best, they consider technology as having freed them from the mundane aspects of healthcare administration so they can spend more time with patients.

Godspeed to our efforts at making technology the best for them.

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Currently there are "3 comments" on this Article:

  1. Apologies Daniel if you felt personally attacked. Keeping in mind that my complaint was with Pragma, who claimed to cite studies showing EHRs improve quality of care, I stand by my observation that your policy brief, though excellent, also fails to support his argument.

    Though you have a section in the brief about improving quality, no research is cited. Your footnotes in that section cite only three sources. Two of those are papers that also look to the future for what EHRs may do for us but have no measurement of anything in the here and now. (The other source was a vendor website advertising their wares (and one of their links is broken)).

    Again, my sincere apologies if you felt attacked; I’ll accept that perhaps I shouldn’t have dismissed your work on the basis of who published it. But taking your advice and looking at your paper, an excellent resource that I would encourage anyone to read, does not advance Pragma’s claim that it is a study showing concrete evidence that EHRs improve the quality of care.







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